key: cord-0761325-jmf14euc
authors: Potter, Alexandra L; Rosenstein, Allison L; Kiang, Mathew V; Shah, Shivani A; Gaissert, Henning A; Chang, David C; Fintelmann, Florian J; Yang, Chi-Fu Jeffrey
title: Association of computed tomography screening with lung cancer stage shift and survival in the United States: quasi-experimental study
date: 2022-03-30
journal: BMJ
DOI: 10.1136/bmj-2021-069008
sha: e75aa30ffdce662a3b3e2f7a5673e99cfa3a9183
doc_id: 761325
cord_uid: jmf14euc

OBJECTIVE: To determine the effect of the introduction of low dose computed tomography screening in 2013 on lung cancer stage shift, survival, and disparities in the stage of lung cancer diagnosed in the United States. DESIGN: Quasi-experimental study using Joinpoint modeling, multivariable ordinal logistic regression, and multivariable Cox proportional hazards modeling. SETTING: US National Cancer Database and Surveillance Epidemiology End Results program database. PARTICIPANTS: Patients aged 45-80 years diagnosed as having non-small cell lung cancer (NSCLC) between 1 January 2010 and 31 December 2018. MAIN OUTCOME MEASURES: Annual per cent change in percentage of stage I NSCLC diagnosed among patients aged 45-54 (ineligible for screening) and 55-80 (potentially eligible for screening), median all cause survival, and incidence of NSCLC; multivariable adjusted odds ratios for year-to-year changes in likelihood of having earlier stages of disease at diagnosis and multivariable adjusted hazard ratios for changes in hazard of death before versus after introduction of screening. RESULTS: The percentage of stage I NSCLC diagnosed among patients aged 55-80 did not significantly increase from 2010 to 2013 (from 27.8% to 29.4%) and then increased at 3.9% (95% confidence interval 3.0% to 4.8%) per year from 2014 to 2018 (from 30.2% to 35.5%). In multivariable adjusted analysis, the increase in the odds per year of a patient having one lung cancer stage lower at diagnosis during the time period from 2014 to 2018 was 6.2% (multivariable adjusted odds ratio 1.062, 95% confidence interval 1.048 to 1.077; P<0.001) higher than the increase in the odds per year from 2010 to 2013. Similarly, the median all cause survival of patients aged 55-80 did not significantly increase from 2010 to 2013 (from 15.8 to 18.1 months), and then increased at 11.9% (8.9% to 15.0%) per year from 2014 to 2018 (from 19.7 to 28.2 months). In multivariable adjusted analysis, the hazard of death decreased significantly faster after 2014 compared with before 2014 (P<0.001). By 2018, stage I NSCLC was the predominant diagnosis among non-Hispanic white people and people living in the highest income or best educated regions. Non-white people and those living in lower income or less educated regions remained more likely to have stage IV disease at diagnosis. Increases in the detection of early stage disease in the US from 2014 to 2018 led to an estimated 10 100 averted deaths. CONCLUSIONS: A recent stage shift toward stage I NSCLC coincides with improved survival and the introduction of lung cancer screening. Non-white patients and those living in areas of greater deprivation had lower rates of stage I disease identified, highlighting the need for efforts to increase access to screening in the US.

Sensitivity analyses were conducted allowing for up to two joinpoints. We chose to conduct these sensitivity analyses to determine whether the Joinpoint Software would select more than one joinpoint, as this would indicate that there were two statistically significant changes in the rate of stage I disease identified during the study period. If two joinpoints were identified, this would require further investigation to understand other possible contributing factors that may change the rate of stage I disease identified. Importantly, however, these sensitivity analyses did not change our results.

Patient subgroups were determined according to patient race and area of residence (high income vs. low income, well-educated vs. less-educated). The National Cancer Data Base records median household income and the percent of adults age 25 and over who did not graduate from high school for each patient's area of residence. The income groups evaluated in the present study were defined according to median household income quartiles based on income ranges among all United States zip codes. The education groups evaluated in the present study were defined according to quartiles of the percent of adults age 25 and over who did not graduate from high school based on 2016 American Community Survey Data.

The lung cancer screening rates used in Supplemental 

To estimate the number of deaths averted due to a shift towards earlier stages of disease diagnosed after the introduction of lung cancer screening in the U.S., we did the following. First, we evaluated changes in the hazard of death before and after the introduction of lung cancer screening using a Cox proportional hazard model, adjusting for important patient, hospital, and regional characteristics. The covariates included in this model were patient sex, age, race/ethnicity, median census tract income, percentage of individuals without a high school education living in that patients' zip code, insurance status, distance from hospital, comorbidity score, histologic subtype, facility type (e.g., community, academic), metropolitan/urban/rural status, region of residence (e.g., northeast, east north central, pacific), clinical stage group, receipt of immunotherapy, receipt of chemotherapy, receipt of radiation, and receipt of surgery. Second, using the results of the Cox proportional hazards model, we 

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